CASE REPORT

PATIENTS IDENTITY
Name : Mr.S
Age : 33 y/o
Sex : Male
Marital Status : Not Married
Occupation : Private employees
Religion : Moslem
Edu. Background : High School
Address : Central Java
Admission date : Saturday, January 28th, 2017 ER:12.00
Numfor:22.30
HISTORY OF PRESENT ILLNESS

This 33 yo male were working with his colleagues in the

workplace. He climbed up the stairs when he suddenly lost
his footing and slid 15 meters to the ground. His friend
who witnessed the fall said that his head banged to the
floor first. His friend said that the patient is unconscious
and the patient had a large gash over his upper head, but
did not vomit and no blood coming from the mouth, nose,
ears. The patient was immediately taken to the
emergency room at RS TNI AL dr. Mintohardjo and got a
few stitches.
 According to the man's
family, the patient was in
good health prior to the
History of past accident, with no history of
diseases allergies, anemia, bleeding
disorders, diabetes mellitus
and hypertension.

Same illness like the patient (-)

Family Hypertension (-)
history of Diabetes Mellitus (-)
diseases Heart disease (-)
Kidney disease (-)
 PHYSICAL EXAMINATION (1)
General Severely ill
condition
Stupor
Consciousness GCS (E3 V1 M3)

Blood pressure: 90/50 mmHg

Temperature: 36,5 celcius
Vital signs Heart rate: 90 x/min
Respiration rate: 22 x/min
 PHYSICAL EXAMINATION(2)

Normocephalic, with vulnus laceratum

Head
Eyes
Anemic conjunctiva -/- , Icteric sclera -/-, DLR +/+, NDLR
+/+
Mouth
Lip: cyanosis (-) dryness (-)

Neck
Lymph gland & Thyroid gland is not palpable, neck
stiffness (-)
PHYSICAL EXAMINATION(3)
Heart
S1-S2 regular, gallop (-) , murmur (-)

Lung
Vesicular (+/+) , rhonchi (-/-) , wheezing (-/-)

Abdomen
Supel , organomegaly (-) , bowel sound 3x/m

Extremity
Warm
+/+ Oedema -/-
+/ + -/-
 NEUROLOGICAL STATUS

Sensibility Pathological Reflex

Cant be examined Hofman-Tromner : -/-
Babinski : -/-
Chaddok : -/-
Schaeffer : -/-
Motoric Oppenheim : -/-
Gordon : -/-
Strength :
Tidak tampak lateralisasi Physiological Reflex
Biseps : +2/+2
Triseps: +2/+2
Patella: +2/+2
Achilles: +2/+2
NEUROLOGICAL STATUS
Meningeal Sign

Brudzinski II : (-)
Kernig : (-)
Laseque : (-)

Speech

Patient was unable to talk.

CRANIAL NERVES EXAMINATION

N. II
Direct light reflex : +/+
Non direct light reflex : +/+
 Test
LABORATORY EXAMINATION
Result Normal
Routine Blood Test ( 29/01/2017)
Leucocyte 14.800 5.000-11.000 /L
Erythrocyte 4.85 4.6-6.2 juta/L
Hemoglobin 14.2 14-16 g/dL
Hematocrit 42 42-48%
Thrombocyte 205.000 150-450 ribu/L
Liver Function
AST ( SGOT) 51 < 35 U/I
ALT (SGPT) 19 < 55 U/I
Kidney Function
Ureum 27 17 43 mg/Dl
Creatinin 1.0 0.7 1.3 mg/dL
Electrolite
Natrium (Na) 141 134 146 mmol/L
Kalium (K) 3.59 3.4 4.5 mmol/L
Clorida (Cl) 104 96 106 mmol/L
Glucose test 149
 LABORATORY EXAMINATION
Test Result Normal
Urinalysis ( 30/01/2017)
Color Yellow Yellow
Blood +++/250 Negatif
Glucose Negatif Negatif
Leukocytes Negatif Negatif
Bilirubin Negatif Negatif
Ketone +/10 Negatif
Spesific Gravity 1.010 1.003 1.031
pH 6.5 4.5 8.5
Protein Negatif Negatif
Urobilinogen +-/norm 3.5 - 17
Nitrite Negatif Negatif
 LABORATORY EXAMINATION

Test Result Normal

microscopic urinalysis ( 30/01/2017)
Red Blood Cells 50-70 0-1
White Blood Cells 4-6 0-5
Epithelial Cells Positif Positif
Bacteria, Yeast and Parasites Negatif Negatif
Cylinder Negatif Negatif
crystal Negatif Negatif
others Negatif Negatif
CT-Scan Examination

Hyperdense lesion with an irregular shape

surrounded by perifocal edema in the right
cerebellum close to 4th Ventricle
There are no signs of pathologic
calcification
Normal ventricle system and cisterna
Normal cerebellum and infratentorial region
Normal Subdural space and meningeal
layer
Normal skull

The Conclusions :
Right cerebellum hemorrhage
ASSESMENT

Assesment 1
Clinical : Unconsciousness
Etiology : Right cerebellum Hemorrhage
Pathology : Hemorrhage
Topical : Right cerebellum
THERAPY

IVFD RL 14 tpm
Ceftriaxone Inj. 2x1 g
Ketorolac Inj. 3x1 amp
Manitol Inj. 3x125 cc
Citicoline Inj. 2x500 mg
Transamin Inj. 3x500 mg
Head Elevation 20o
Liquid diet 6x300 mL
 FOLLOW UP DAY 1-4

30 January 2 February 2017

S O A P
Dizziness Consciousness : GCS X1 : IVFD RL 14 tpm
(+) E4M5V2 Clinical : Ceftriaxone Inj. 2x1 g
BP 110/70mmhg Unconsciousness Ketorolac Inj. 3x1 amp
General examination : - Etiology : Right Manitol Inj. 3x125 cc
Neurological examination : - cerebellum Hemorrhage Citicoline Inj. 2x500 mg
Pathology : Hemorrhage Transamin Inj. 3x500 mg
Topical : Right Head Elevation 20o
cerebellum Liquid diet 6x300 mL
 FOLLOW UP DAY 5

3 February 2017
S O A P
Dizziness Consciousness : GCS X1 : IVFD RL 14 tpm
(+) E4M6V2 Clinical : Ceftriaxone Inj. 2x1 g
BP 120/80mmhg Unconsciousness Ketorolac Inj. 3x1 amp
General examination : - Etiology : Right Manitol Inj. 2x125 cc
Neurological examination : - cerebellum Hemorrhage Citicoline Inj. 2x500 mg
Pathology : Hemorrhage Transamin Inj. 3x500 mg
Topical : Right
cerebellum Head Elevation 20o
Liquid diet 6x300 mL
 FOLLOW UP DAY 6

4 February 2017
S O A P
Dizziness Consciousness : GCS X1 : IVFD RL 14 tpm
(+) E4M6V2 Clinical : Ceftriaxone Inj. 2x1 g
BP 100/70mmhg Unconsciousness Ketorolac Inj. 3x1 amp
General examination : - Etiology : Right Manitol Inj. 1x125 cc
Neurological examination : - cerebellum Hemorrhage Citicoline Inj. 2x500 mg
Pathology : Hemorrhage Transamin Inj. 3x500 mg
Topical : Right (STOP)
cerebellum
Head Elevation 20o
 FOLLOW UP DAY 7

5 February 2017
S O A P
Dizziness Consciousness : GCS X1 : Venflon
(+) E4M6V2 Clinical : Cefixime 2x200mg
BP 110/80mmhg Unconsciousness Paracetamol 2x750 mg
General examination : - Etiology : Right Citicoline 2x500 mg
Neurological examination : - cerebellum Hemorrhage Betahistin 3x1 tab
Pathology : Hemorrhage Flunarizin 2x5 mg
Topical : Right Pirazetam 2x1200 mg
cerebellum
Head Elevation 30o
 FOLLOW UP DAY 8

6 February 2017
S O A P
Dizziness Consciousness : GCS X1 : Venflon
(+) E4M6V2 Clinical : Cefixime 2x200mg
BP 110/70mmhg Unconsciousness Paracetamol 2x750 mg
General examination : - Etiology : Right Citicoline 2x500 mg
Neurological examination : - cerebellum Hemorrhage Betahistin 3x1 tab
Pathology : Hemorrhage Flunarizin 2x5 mg
Topical : Right Pirazetam 2x1200 mg
cerebellum
Head Elevation 30o
 FOLLOW UP DAY 9

7 February 2017
S O A P
Dizziness Consciousness : GCS X1 : Venflon
(+) E4M6V2 Clinical : Cefixime 2x200mg
BP 120/70mmhg Unconsciousness Paracetamol 2x750 mg
General examination : - Etiology : Right Citicoline 2x500 mg
Neurological examination : - cerebellum Hemorrhage Betahistin 3x1 tab
Pathology : Hemorrhage Flunarizin 2x5 mg
Topical : Right Pirazetam 2x1200 mg
cerebellum
Head Elevation 30o
THANK YOU